Patrick Walsh Nine Mile Point – Human Performance
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Transcript of Patrick Walsh Nine Mile Point – Human Performance
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Patrick WalshNine Mile Point – Human Performance
HPRTC Conference -June 10
Improving Administrative Procedure Use and Adherence
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Let’s get started
Levels of Lucky
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What’s the Big Deal with Admin Procedures?
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What’s the Big Deal with Admin Procedures?
Required by Technical Specifications Provide uniform standards and expectations Protect the people Protect the reactor Protect the public
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How’s your station doing?
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Consequences
What can happen when we fail to follow our standards and
expectations, as outlined in our administrative procedures?
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Gulf Oil Spill
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Gulf Oil Spill
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Exxon Valdez ?
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Bhopal, India
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Consequences? Challenges to nuclear safety Challenges to personnel safety Increased regulatory oversight Loss of stakeholder trust
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NMP’s Journey?
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What started it all? Dec 07 – Jan 08 incurred a significant amount
of unavailability on NMP Unit 2 Service Water System.
Nov 08 – Service Water Foreign Material Intrusion event while cleaning the NMP Unit 2 intake. This event moved our component cooling water performance indicator to white. Station moved to NRC regulatory response column.
Failed NRC 95-001 inspection.
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Actions taken? Each Department identified the top 3 admin
procedures that challenge them and created an improvement plan
Procedure Compliance Review Report Admin Procedure “In Hand” Day Supervisor 20 day habit changing activity Required 1 documented observation per month
of administrative procedure compliance Frequent communications to the station in our
weekly Station Updates regarding actions to raise our standards for compliance with administrative procedures
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Procedure Compliance Review Report Initiated for procedure violations as
determined by procedure compliance review team.
Requires the supervisor and the employee(s) that contributed to the procedure compliance event to discuss the issue, evaluate culpability and determine what actions are required to improve performance.
Reviewed by the next level supervisor. Evaluated by the HU lead when completed.
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Procedure Compliance Review ReportAttachment 1 – Procedure Compliance Review Report CR Number: Short Description of procedure non-compliance event: 1. Procedure(s) and section(s) not complied with: 2. Person(s) not complying with procedures listed above: 3. Why is this a procedure non compliance event?
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Procedure Compliance Review Report 4. Review/discuss the issue with personnel involved and, using the “Culpability
Model” (Human Error Review and Decision Tree, determine where the culpability lies for the procedure non compliance event.
Results of Review: Was the task and specific action covered by written work instructions or
through standards and expectations? __ Yes __No Were the instructions, standards, and expectations available, workable,
intelligible, and correct? __ Yes __No
Pass the substitution test? __ Yes __No Is there a history of inappropriate acts involving procedure adherence?
__ Yes __No Poor individual or Team Performance? __ Yes __No Reckless Procedure Noncompliance? __ Yes __No Management Control System Induced Violation? __ Yes __No Blameless Error? __ Yes __No
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No
START==> For each specific error . . .
Were the actions as intended?
Pass the substitution
test?Unauthorized
substance?
History of inappropriate
acts?
Were the consequences as intended?
Medical condition?
Were the instructions, standards, and
expectations available, workable, intelligible, and
correct?
Deficiencies in training & selection or
inexperience?
Sabotage, malevolent
damage, suicide, etc.
Substance abuse
without mitigation
Substance abuse with mitigation Poor Individual/
Team Performance
(poor use of HU Tools) OR
Possible reckless violation
Management Control System induced
violation/ Supervisor culpability
Poor Individual or
Team Performance -
Possible negligent
error
Management Control System
induced error
Corrective training or counselling indicated
Blameless error
NoYes
Yes
Yes
No Yes
Yes
Yes
Yes
No
No
Yes
Yes
Human Error Review & Decision Tree
Reason, Managing the Risks of Organizational Accidents, 1997
Was the task and specific action covered by written
work instructions or through standards and
expectations?
NoNo
Yes, Most others would probably have taken the same action or likely could have made the same
error.
No. Others would not have taken the same
action.
No
May still warrant management actions to prevent recurrence,
e.g., enhance procedure
No
Did Supervisor negatively influence behavior?
NoYes
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Procedure Compliance Review Report 5. Why did the listed personnel not comply with the procedure? (Check one
and describe below) Did not know the requirement. Did not understand the requirement. Understood the requirement, but decided not to comply. Thought they understood the requirement Did not reference the procedure Procedure guidance was vague
Explanation: 6. What could be done to prevent others from making the same procedure
error?
7. Are there procedure changes or other actions (e.g., training, coaching etc) required based on this review?
8. Has a PCR been initiated? (List CA and PCR Numbers below)
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Administrative Procedure “In Hand Day”Weekly activity for the station to review an administrative
procedure.
The procedure of the day is communicated each Tuesday as part of the weekly Station Update that is reviewed at shop / department meetings.
Expectations for “In Hand Day”. Each site supervisor will have a copy of the procedure
with them that day. Supervisors are expected to review the procedure as part
of shop / department briefings. Work groups are expected to have the procedure
available for review.
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20-Day Habit Changing ActivityAll supervisors and above are issued cards to document at least two interactions per day to verify that employees are performing work in accordance with the applicable administrative procedure.
Purpose of the exercise is to develop habits for:
Daily interaction and discussion of administrative procedure compliance between leaders and employees. Frequent reviews of administrative procedure requirements for activities being performed. Supervisors to observe and coach on administrative procedure compliance. Personnel validating what the procedure requires
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20 Day Habit changing activityAdministrative Procedure Compliance 20-Day Habit Changing Program
Name: __________________________ Title: ______________ Department: _________________
Purpose: To focus the stations supervisory team on compliance with our administrative requirements by implementing a daily requirement for station leaders to verify that they and the personnel working for them are performing activities in accordance with our station administrative procedures.
Each supervisor and above will document daily that they have observed and re-enforced compliance with our site administrative procedures.
Each supervisor will interact with at least 2 direct reports each working day to evaluate compliance with administrative procedures.
Each supervisor is required a minimum of 40 documented reviews of administrative procedure compliance.
Each supervisor will have their supervisor review progress weekly and initial on back page.
Date Personnel
observedActivity Applicable
Procedures Referenced
Coaching required?
Positive re-enforcement?
Initials
1
2
3
4
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Observation DocumentationThe station’s management observation program expectations were revised to require each participant in the observation program to clearly document in at least one observation per month that they evaluated compliance with at least one administrative procedure and provided feedback to the personnel being observed.
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How’s it working?
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Summary